Sexual Health, STIs, & Family Planning 2023.pptx

Sexual Health, STIs, Contraception and Family Planning DR. CONTRERAS PREVENTIVE MEDICINE FA L L 2 0 2 3 Sexual Health & STIs Objectives 1. Define sexual health according to the World Health Organization 2. 3. 4. 5. 6. 7. 8. 9. (WHO). List the key principles for STI prevention and control accor...

Sexual Health, STIs, Contraception and Family Planning DR. CONTRERAS PREVENTIVE MEDICINE FA L L 2 0 2 3 Sexual Health & STIs Objectives 1. Define sexual health according to the World Health Organization 2. 3. 4. 5. 6. 7. 8. 9. (WHO). List the key principles for STI prevention and control according to the CDC. Identify the epidemiology, prevalence, and potential complications for each of the following: chlamydia, gonorrhea, HIV, HPV, HSV, and syphilis Describe behaviors that may be considered “risky” for STI transmission and further suggest non-risky alternatives. Discuss the importance of pre- and post-exposure prophylaxis for HIV. Explain the importance of contact tracing for sexually transmitted infections. Explain the concept of Expedited Partner Therapy (EPT). List STIs that are considered reportable conditions. Identify challenges or barriers that both providers and patients may face when addressing issues of sexual health. Sexual Health World Health Organization  State of physical, mental, and social well-being in relation to sexuality.  Requires a positive and respectful approach to sexuality and sexual relationships. STI Overview STI Facts  More than 1 million sexually transmitted infections (STIs) are acquired every day worldwide, the majority of which are asymptomatic.  Each year there are an estimated 374 million new infections with 1 of 4 curable STIs: chlamydia, gonorrhea, syphilis and trichomoniasis.  STIs are preventable:  Abstinence  Condoms  Fewer partners – one partner  Get vaccinated – HPV  Get tested – many STIs do not have symptoms 5 Major Strategies for STI Prevention Center for Disease Control and Prevention 1. Education and counseling of patients at risk 2. Identify asymptomatically infected patients 3. Effective diagnosis, treatment and counseling of infected persons 4. Evaluation, treatment, and counseling of sex partners 5. Pre-exposure vaccination (HPV) of patients at risk STI Preventive Counseling  Routinely obtain sexual history  Be nonjudgmental and empathetic The 5 P’s 1. Partners 2. Practices 3. Protection (from STIs) 4. Past history (of STIs) 5. Prevention (of pregnancy) Partners  Do you have sex with men, women, or both?  How many partners have you had sex with in the last 6 months? 5 years? Lifetime?  Is it possible that any of your sex partners had sex with someone else while they were still in a sexual relationship with you? Practices  To understand your risks for STIs, I need to understand what kind of sex you’re having (e.g. oral, vaginal, anal, sharing sex toys).  What parts of your body do you use for sex?  What parts go where when you are sexually active? Protection What do you do to protect yourself from STIs and HIV? Do you use condoms: never, sometimes, or always? There are a lot of reasons why people don’t use condoms. Can you tell me why you are not using them for sex? Do you have any concerns about HIV infection or other STIs? Past History Have you ever had a STI?  If so, which ones? (may need to list out/name)  If so, when? Have any of your sexual partners had a STI?  If so, which ones? (may need to list out/name)  If so, when? Have you ever been tested for a STI? (or other STIs)?   If so, which ones? (may need to list out/name) If so, when? Prevention of Pregnancy Are you concerned about getting pregnant or getting your partner pregnant? What are you doing to prevent pregnancy? Do you want information on birth control? Do you have any questions or concerns about pregnancy prevention? The 6th P =“Plus” Assess for: Trauma Violence Sexual satisfaction Sexual health concerns/problems Support for gender identity and sexual orientation USPSTF Recommendations Nonpregnant women STI Chlamy dia2 Pregnant women Men Not at At Not at At Not at At increase increase increase increase increase increase d risk d risk* d risk d risk* d risk d risk† C A C B I I Gonorrh D ea3 B I B D I Syphilis4 D A A A D A HIV5 C A A A C A Hepatiti s B6 D D A A D D Hepatiti s C7 D I — — D I HSV8 D D D D D D HPV9‡ I I — — — — Risky Behaviors  Unprotected sex (vaginal, oral, or anal)  Multiple partners (or partner who has multiple partners)  History of STIs  Misuse of alcohol or use of recreational drugs  Much less likely to use protection  IV drug user  Sharing needles  Age < 25 y/o  Sex work (voluntary exchange of sex for compensation e.g. money, drugs, etc.)  Ask additional question:  Is there anything else about your sexual practices that I need to know about? Chlamydia, gonorrhea, and syphilis Chlamydia & Gonorrhea Chlamydia Gonorrhea  Most commonly reported  Second most commonly STI in US  Highest in ages < 24  Every 3 to 6 months if at increased risk  Retest approximately 3 months after treatment  Complications reported STI in US  Highest in ages < 24  Every 3 to 6 months if at increased risk  Retest approximately 3 months after treatment  Complications    PID Ectopic pregnancy Infertility    PID Ectopic pregnancy Infertility Syphilis  Caused by bacteria Treponema Pallidum  Syphilis stages– primary (sores), secondary (rash), latent (symptoms disappear), tertiary (organ damage)  Testing   nontreponemal test, VDRL or RPR – Estimated sensitivity 78-86% in Primary, 95-100% for later stages treponemal test, Confirmatory Tests – FTA-ABS or TP-PA, specificity of 96%  Congenital syphilis HIV At the end of 2019, an estimated 1,189,700 people aged 13 and older had HIV in the United States. PrEP (pre-exposure prophylaxis) and PEP (postexposure prophylaxis) HIV new cases HIV by Age New HIV Diagnoses in theUS and Dependent Areas by Age at Diagnosis, 2018 Age (Years) Number of Diagnoses 13-14 12 15-19 1,256 20-24 4,867 25-29 6,103 30-34 5,233 35-39 3,445 40-44 2,540 45-49 2,094 50-54 1,883 55-59 1,599 60-64 901 65 and older 702 HIV by Race/Ethnicity New HIV Diagnoses Among Adults and Adolescents in the US and Dependent Areasa by Race/Ethnicity, 2018 Race or Ethnicity Number of Diagnoses American Indian/Alaska Native 200 Asian 635 Black/African Americanb 12,827 Hispanic/Latinoc 7,999 Native Hawaiian and other Pacific Islander 65 White 7,831 Multiracial 792 HIV by mode of transmission New HIV Diagnoses Among Adults and Adolescents in the US and Dependent Areasa by Transmission Category, 2020 Transmission Category Males Females Total Male-to-male sexual contact 20,758 NA 20,758 Injection drug use 1,198 857 2,055 Male-to-male 1,109 sexual contact and injection drug usec NA 1,109 Heterosexual contactd 2,051 4,575 6,626 Perinatale 9 51 60 Otherf 20 7 27 70% HIV by Top 10 states New HIV Diagnoses Among Adults and Adolescents by Top 10 States, 2018 State Number of Diagnoses California 3,924 Texas 3,548 Florida 3,408 Georgia 1,977 New York 1,963 Illinois 1,096 North Carolina 1,079 Ohio 888 New Jersey 805 Pennsylvania 775 Herpes Simplex Virus (HSV)  572,000 new genital herpes infections in the United States annually.  11.9 % of persons aged 14 to 49 years have HSV-2 infection  Women > men  Black > white  Many are asymptomatic   Most infected persons may be unaware of their infection. An estimated 87.4% of 14 to 49 year-olds infected with HSV-2 have never received a clinical diagnosis.  Complications  Life-long viral infection Human Papillomavirus (HPV)  HPV is the most common STI.  About 43 million HPV infections in 2018, many among people in their late teens and early 20s.  CDC recommends HPV vaccination for:   All preteens (including boys and girls) at age 11 or 12 years (or can start at age 9 years). Everyone through age 26 years, if not vaccinated already.  Complications  Genital warts and cervical (and other) cancers Reportable STIs HIV Syphilis Chlamydia Gonorrhea Chancroid (Hemophilus ducreyi) Expedited Partner Therapy  The clinical practice of treating sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions to the patient to take to his/her partner without the health care provider first examining the partner.  Facilitates partner management Contraception, Family Planning, & Pregnancy Objectives 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Compare and contrast the different contraception methods. Define emergency contraception including indications, preparations, and recommendations. Discuss the various barriers (emotional, financial, educational, cultural, religious, etc.) people face regarding contraception methods. Discuss the goals and benefits of both pre-conceptual counseling and prenatal care. Identify the consequences for lack of pre-conceptual counseling and prenatal care. Discuss the importance of folic acid supplementation and define the recommended dosage during pregnancy. Explain prenatal labs that are done routinely and discuss at what point in the pregnancy they are to be performed. List common risk factors for developing pregnancy complications (for both mother and fetus). Define the term advanced maternal age and further discuss the health concerns for both the mother and fetus. Discuss travel & immunizations during pregnancy. Discuss the risks of smoking, alcohol, and drug use in pregnancy and the effects on both the mother and fetus. Contraception vs. Responsible Sexual Behavior  Contraception Birth control, method or devise used to prevent pregnancy  Responsible Sexual Behavior  Respecting your partner, having open communication, and taking precautions to prevent sexually transmitted infections  E F F E C T IV E N E S S O F FA M ILY P L A N N IN G M E T H O D S * *The percentages indicate the number out of every 100 women who experienced an unintended pregnancy within the first year of typical use of each contraceptive method. MOST EFFECTIVE 6-12 p re gn a n cie s p e r 100women in a y e a r Im p la n t PER M A N EN T ST E R ILI Z A T IO N R E V E R SIB LE R E V E R SIB LE Less than 1 pregnancy per 100women in a y e a r A fte r p ro ce d u re , little o r n o th in g to d o o r re m e m b e r. U se a n o th e r m e th o d fo r fi rst 3 m o n th s (H y ste ro sco p ic, V a se cto m y). O n ce in p la ce , little o r n o th in g to d o o r rem e m b er. In tr a u te r in e D e v ic e (IU D ) 0 .2 % LNG 0.05% 0 .8 % CopperT G e t re p e a t in jectio n s o n tim e . Takeapilleachday. Injectable P ill S U N M O N T U E S W ED T H U R 6% 1 2 Female (A b d o m in a l, La p a ro sco p ic, a n d H y ste ro sco p ic) 0 .1 5 % 0 .5 % K e e p in p la ce , ch a n g e o n tim e . Patch FR I Male (Vasectomy) U se co rre ctly e v ery tim e y o u h a v e se x. R in g D ia p h ra g m SA T 9% 9% 9% 12% 3 4 U se co rrectly e v e ry tim e y o u h a v e se x. M a le C o n d o m LE A ST EFFECTIVE C S2 48 1 2 4 Sp o n g e W it h d r a w a l 12% R E V E R SIB LE 18 or more pregnancies per 100women in a y e a r F e m a le C o n d o m 18% N u llip a ro u s W o m e n 22% 21% 24% P a ro u s W o m e n C o n d o m s s h o u ld a lw a y s b e u s e d to r e d u c e th e r is k o f s e x u a lly tr a n s m itte d in f e c tio n s . F e r tility A w a r e n e s s - B a s e d M e th o d s S p e r m ic id e 28% JA N U A RY Abstain or use condomson fertiledays. 1 8 2 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 O t h e r M e t h o d s o f C o n t r a c e p t i o n : (1 ) La cta tio n a l A m e n o rrh e a M e th o d (LA M ): is a h ig h ly e ff e c t iv e , t e m p o ra r y m e t h o d o f c o n t r a c e p t io n ; a n d (2 ) E m e rge n cy C o n tra ce p tio n : e m e r g e n c y c o n t r a c e p t iv e p ills o r a c o p p e r IU D a f t e r u n p r o t e c t e d in t e r c o u r se s u b s t a n t ia lly r e d u c e s ris k o f p r e g n a n c y . 24% AdaptedfromWorldHealthOrganization(WHO)DepartmentofReproductiveHealthandResearch,JohnsHopkinsBloombergSchoolofPublicHealth/CenterforCommunicationPrograms(CCP).Knowledgeforhealthproject. F a m ily p la n n in g : a g lo b a l h a n d b o o k f o r p r o v id e r s (2 0 1 1 u p d a t e ). B a ltim o r e , M D ; G e n e v a , S w it ze r la n d : C C P a n d W H O ; 2 0 1 1 ; a n d T r u s se ll J . C o n tr a c e p t iv e f a ilu r e in t h e U n it e d St a t e s . C o n t r a c e p t io n 2 0 1 1 ;8 3 :3 9 7 – 4 0 4 . Barriers to contraception Lack of education Language barrier Geographic location Social stigma Unsupportive partners Unavailability of resources Cost/insurance coverage Spiritual/religious beliefs Institutional Legislative Healthcare inequities Pre-Conception Counseling  Approximately 45% of all pregnancies that occur in the United States are unintended.   Ask women of reproductive age about intention to become pregnant. Include preconception care tailored to patients’ intentions.  Preconception care is a set of interventions aimed at identifying and modifying biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management. Recommendations:  Family planning  Assess BMI  Counsel those w/ DM  Screening and treatment for STIs and other communicable diseases  Immunizations- hepatitis B; influenza; measles, mumps, rubella; Tdap; and varicella  Review medications – teratogenic effects (e.g. acne, asthma, HTN, Hyperthyroidism, seizure d/o) Pregnancy  CDC recommends that all pregnant women get tested for: HIV  hepatitis B virus (HBV)  hepatitis C virus (HCV)  syphilis  Prenatal vitamin supplementation  Folic acid 400mcg daily  Prevention of neural tube defect – spina bifida  Never too late but should start before 20 weeks  Birth defect occurs in the first trimester  Check-ups  Starting at 6 weeks  q4-6 weeks until 36 weeks  q1-2 weeks until delivery (40 weeks)  Pregnancy screenings Rh(D) Incompatibility  Type and screen 1st prenatal visit  Women who are Rh-negative should be given anti-D immunoglobulin at 28 weeks gestation, and again within 3 days of delivery to prevent alloimmunization (if the infant is Rh-positive.) Bacteriuria- 1st visit Iron deficiency- before 3rd trimester Gestational DM @ 24-28 weeks Offer genetic testing, aneuploidy screening Avoid during pregnancy  Foods: Unpasteurized milk  Raw and undercooked seafood, eggs, and meat  Refrigerated pate’, meat spreads, and smoked salmon  Hot dogs, luncheon meats, and cold cuts  Travel  Air travel generally is safe for pregnant women until four weeks before the expected date of delivery.  Hot tubs/ saunas  Hair dyes/treatments  Advanced Maternal Age (AMA)  Pregnancy at age 35 or older        Decreased fertility HTN more common Increased risk of gestational diabetes Increased risk of birth defects Increased risk of multiple pregnancy Increased risk of preterm labor More likely to require C-section References American Academy of Family Physicians (AAFP). https://www.aafp.org/pubs/afp/issues/2008/03 15/p819.html CDC. STI Data & Statistics https://www.cdc.gov/std/statistics/default.htm ?CDC_AA_refVal=https%3A%2F%2Fwww.cdc. gov%2Fstd%2Fstats%2Fdefault.htm U.S. Preventive Services Task Force (USPSTF) https://www.uspreventiveservicestaskforce.or